Individuals who are enrolled in both Medicare and Medicaid (often called dually eligible or duals) have attracted increased health policy attention in recent decades due to their disproportionate use of health care services and costs. Duals are a vulnerable population as they are generally sicker than the elderly population as a whole, more likely to be in need of long-term care, more likely to receive care in low-resource neighborhoods, and are subject to misaligned and conflicting policy incentives from Medicare and Medicaid. Nursing homes are a major site of care for duals. The nursing home sector has long been a target of concern about low quality of care, and duals are often disproportionately affected by these quality problems. In 2002 the Centers for Medicare and Medicaid Services launched a public reporting initiative (Nursing Home Compare) aimed at improving quality of care for nursing home residents in part by guiding consumers to higher quality nursing homes. However, studies of consumer response to Nursing Home Compare have revealed a small and inconsistent market share response. These lukewarm effects have been disappointing and somewhat puzzling, but they may be masking substantial heterogeneity of effect-duals may be much less likely to respond to, and benefit from, Nursing Home Compare than non-duals. Our preliminary work reveals that, rather than choosing higher-quality facilities, duals have increased their propensity to be admitted to low- quality facilities under public reporting. In this mixed methods project, we propose to examine the extent to which duals have benefited (or not) from Nursing Home Compare, to assess the importance of constrained access by duals in preventing greater use of Nursing Home Compare to choose higher-quality nursing homes, to assess qualitatively the obstacles to duals' use of Nursing Home Compare such that improvements to the report cards may be explored. In particular, information about the quality of nursing homes may not be helpful if an individual 1) lives too far from a high-quality home; 2) depends on Medicaid and no Medicaid beds are available in the high-quality homes; 3) has difficulty accessing or interpreting the quality information. By assessing the relative importance of barriers to effective use of Nursing Home Compare by duals, we will identify the most promising avenues for further investment, e.g. improved usability of quality reports vs improved availability of high-quality providers. These are crucial distinctions affecting access to high-quality care fora particularly vulnerable population. PUBLIC HEALTH RELEVANCE: Our overall goal in this study is to improve the quality of care for nursing home residents who are dually enrolled in Medicare and Medicaid (duals) by critically examining and developing improvements to a major policy initiative -public reporting of quality information- in terms of its effects on, and use by, the duals relative to other consumers. The duals are a particularly vulnerable population responsible for disproportionate health care spending and utilization; thus the effects of major policies on this population is of key policy concern.